Chronic COPD'er, 1 lung, 02 @ 6L/min. What would you do? - page 5
I got a call to go see one of my HH patients, who I am very familar with, because the family reported that her/his 02 sats were hanging in the 70's all day and even though she/he was not SOB they... Read More
Jan 28, '07Joined: Dec '02; Posts: 1,368; Likes: 997I don't wanna-be a doctor...I wanna-be a firefighter, but I am too claustrophobic to put on an airpack.
Jan 29, '07"Doctor wanna be" was a term used as a knee jerk reaction to the poster who oh so politely referred to HH nurses as incompetent to care for patients in acute situations. I apoligize to any paramedics for my reaction and choice of words.
I worked in the hospital for 31 years. As a charge nurse I ran many a code and respected for my skills. HH is a whole new ball of wax for me. The only tools at my disposal are BP cuff, stethoscope, thermometer and pulse oximeter. I did call the doctor....that was a no brainer. The doctor said call 911. The family was unwilling to transport the patient. The patient was just released from the hospital 2 days ago with a right shoulder fractured in 3 pieces. Surgery was not possible due to the respiratory risk and severe osteoarthritis due to years of prednisone. The patient is a DNR. Don't beret me as to why he/she is now on a vent. I don't know. And I also know it's obviously not the fault of the paramedic that he/she is on a vent. Please give me some credit.
CasbeezgirlRN thank you for your sensibility and the nice way you put things in perspective. When I first posted, I had just gotten home, I was so worked up and my fingers were just flying away. I have since spoken with my supervisor who was very supportive and pointed out that a better option would have been to call a private ambulance service for transport. The hospital is literally 2 miles from the home. She explained to me that once the ambulance, that I called, arrived that they are responsible for the patient and their actions whether they be right or wrong. She felt just as CasbeezgirlRN pointed out that right or wrong the paramedic should have acknowledged the family and then went about doing what she felt needed to be done.
I was so angry yesterday evening I could have spit nails. Having calmed down, although I don't agree with the 6L of 02, I realize that level for such a short trip wasn't a big deal. I resented the way she came in and was like "Oh my God! a sat of 73%", acted as though I was invisible and incompetent.
I spoke with the daughter today and she said her Dad/Mom had been in the low 70's since early that morning and never once complained about SOB or anything else for that matter. They thought the low sats were due to the amount of pain medicine he/she was taking and was waiting for it to wear off to see if his/her sats would come up. They didn't and with the temp decided to call the answering service. She also said that the ER doctor told the staff to turn the 02 down to 2L and her 02 sat had remained in the low 70's despite the 6L/min.
I'll let you know more about the patient and the diagnosis when I find out.Last edit by DutchgirlRN on Jan 29, '07 : Reason: Spelling
Jan 29, '07Occupation: Med/Surg Specialty: 19 year(s) of experience in Ortho/MS, SICU,Home Health ; Joined: Dec '06; Posts: 711; Likes: 152Quote from DutchgirlRNYour welcome! HH is a whole different animal. Just for everyone's info, we really do try our very best NOT to call an ambulance for transport unless necessary of course. My agency uses several ambulette services for this purpose and I have sent pt's to the ER this way. However, sometimes, even if it's not a life threatening situation, it's a bit too unstable for an ambulette driver with NO medical training whatsoever. And no, I am not talking about a cold or a hangnail ."CasbeezgirlRN thank you for your sensibility and the nice way you put things in perspective. .
If I feel the pt. may decompensate in the next few minutes, I'm calling the ambulance. And I base that decision on my COMPETENT .
Jan 29, '07Occupation: RN Specialty: 20 year(s) of experience in CVICU-ICU ; Joined: Apr '06; Posts: 353; Likes: 282I've been following this post and havent said anything until now. I think the paramedic was also in the right to do what he was trained to do just as nurses do what we are trained to do. I now work in ICU and I know the therories behind COPD and CO2 retention but thats been mentioned enough already so I wont go into that however in one of the last post's by the OP I see where she says the patient was a DNR. Before working in ICU I spent 8 years in homecare and the rule of thumb was not to call paramedics for DNR patients because paramedics handle any call as a lifesaving call. Maybe that rule has changed because I've been out of HHC for 8 years now. I also wonder if the patient was a DNR why that info wasnt passed onto the hospital by the family in order to avoid a unwanted intubation. I guess that is my pet peeve being in ICU now.
Jan 29, '07the hospital knows this pt all too well and knows about the DNR. Everytime I resume this pt the hospital discharge states "DNR but agreed to temporary intubation". Makes no sense to me either. Alot about DNR's make no sense to me. I read about this elderly woman (80's) who wanted to be a DNR but her family said if she was ever in a critical situation they would tell the doctors and nurses that she was not a DNR and to do all that they could. This woman went out and had a large DNR tatooed on her chest!
What a woman!!!!
Jan 29, '07Occupation: RN - ICU Specialty: 5 year(s) of experience in ICU ; From: US ; Joined: Sep '06; Posts: 1,643; Likes: 1,908As to paramedics being doctor wannabees, not in my case. I'm a degreed Chemical Engineer, and a RN wannabee. No incination to go MD - I'd rather keep a personal and family life, thank you very much!
As a medic since 1991 (& EMT a few years before that), you see lots of "stuff", and it's constantly drilled into you from the start of training that you must be AGGRESSIVE in the care of seriously screwed up patients. It's also emphasized that it's better to explain a sin of commission than a sin of omission.
I'd fault the medic for only going with 6lpm O2. I'm more inclined to go with a non-rebreather at 10-15lpm, but that's driven by my local protocols.
I've been on scenes where physicians and nurses have been there, but the responding crew rarely knows their background/certifications/capabilities. You may have a doc that's 25 years out of school, and has been a Dermatologist ever since (forgetting most of their ER time). If they claim to be a MD or a RN or a paramedic, that's taken with a large grain of salt. I've had people claiming to be paramedics from another state show up on my scene that didn't know 1 end of a stethoscope from another. When faced with a patient that looks sick, sounds sick, measures (by pulse ox, monitor, whatnot) sick, then the medic will tend to aggressively take charge, and treat the patient without delay. This is how we're "programmed." You don't have a lot of time to play 20 questions and assess the level of training of bystanders.
Obviously, most medics are not nurses or physicians. We may not have a full understanding of the underlying pathophysiology of a long term disease process that's plopped a sick patient in front of us. Then again, I suspect that if you grabbed your "average" MD or RN and dumped them in a muddy ditch at 2AM, facing an upside-down car, they might not exactly know the "best" way to handle things. Each medical professional has unique strengths they bring to the table.
If the family & medical personnel on scene expressed concerns about the amount of O2 to be given to the patient during transport, most ambulances have this neat invention called a PHONE. The medic could call & speak to medical control for their recommendation. If in doubt, though, we're taught to give O2.
Jan 29, '07Joined: May '06; Posts: 356; Likes: 13After reading through this post, I am amazed at the similar attitudes of some (not all) of those chiming in saying they are medics. I can see why the OP had "knee-jerk reaction" to the offensive "I am better than you" attitude. I am not an ER or HH nurse, so my experience with medics is very limited. Of the handful I have met, they have all been in casual passing, all have felt the need to tell me how they "once did something better than a nurse." The moment they find out I am a nurse, all of the sudden, they feel like they have something to prove. The funny thing? One of them made up a story, a total blatant lie, just to tell me how he showed some ER nurses up. I know he was lying b/c he was talking about a large teaching hospital (where I happen to work) where "all the nurses were standing around trying to intubate a 6 week old." Do I really need to point out the part of that statement that sounds like bull? I am a full believer in everyone having a job that is necessary and an important part of the team, with different stregnths so I know the "stories" are not a response to me having a "better than you" attitude.
Would it have been so hard to acknowledge the nurse and family by stating that she was following set protocols that require increasing O2 on any hypoxic pt, regardless of potential for CO2 retention? How long would it take to say that.....3 sec max? "I am sorry you disagree, but I am following my protocols."Last edit by lovemyjob on Jan 29, '07 : Reason: forgot something
Jan 29, '07Joined: Feb '06; Posts: 300; Likes: 472[quote=DutchgirlRN;2041266]" I have since spoken with my supervisor who was very supportive and pointed out that a better option would have been to call a private ambulance service for transport. /quote]
I hope you don't think that calling a private service would have gotten your patient treated differently in this situation. Before I entered nursing school I worked for a private service for 7 years and I can tell you this patient would have received the same treatment on my ambulance. They have protocols to follow and answer to the same state authority as 911. Whether you knew it at the time or not I would have considered this an emergent situation. COPD or not...febrile, o2 sats of 73%, and wheezes in the only lung is cause for prompt attention. Probably more prompt attention than a healthy person with those numbers because a person who is already compromised has less ability to recover.
Jan 29, '07Joined: Dec '05; Posts: 860; Likes: 105I don't mean any disrespect or to flame anyone but I think you were out of line. First with the decision to call 911 and the medic arrived you needed to back out of the situation..you did your job you assessed the patient and determined they needed further medical care. You knew something was wrong but not what therefore you can not apply the same patient normal standards to the situation. For example that he tolerates a sat of 80 does not mean all is well and normal at 73 ,therfore do not increase the o2? Then to call the ER doc and cloud his judgement about the man's condition and instructing him to turn the o2 up (he can think for himself)...overstepping bounds. Yes the man's co2 was 152 in ICU and I also would venture to quess that it was at least that at home but we will never know because we can't do abg's at home. I see at times that your concern could have caused harm to the patient and you should have backed out when the medics got there.
Jan 29, '07Occupation: Staff Nurse Specialty: 18 year(s) of experience in Rehab, LTC, Peds, Hospice ; From: US ; Joined: Jan '06; Posts: 593; Likes: 562When I worked in home care, we would have also had to notify the agency supervisor and the patients doctor. I'm curious to see if that was done? I also would've notified 911, but never to get "seen faster". It's my understanding that if it were not a true emergent situation a patient would still have to wait to be seen- ambulance patients are triaged also.
Anything that involves a respiratory problem as you described I would call 911 because I have seen apparently 'stable' patients in those situations go bad very quickly. 911 would be equipped to handle that if it occurred and it seems as if your patient was a very high risk.
As far as some of the posts here, I think some proffesionalism (sp?) is lacking. I totally understand the frustrations involved, but to judge an entire healthcare group- homehealth nurses, wannabee doctors- is just as bad as judging people for their color or sex, don't you think?
Frankly there are incompetant people in every aspect of the healthcare field. The ones that screwed up are going to stand out in your mind, but don't stand for an entire group of people.
My advice- withhold judgement, keep your mind open- there are always things to be learned in every situation, and use these opportunities to educate people.
Jan 29, '07Occupation: RN Specialty: 10 year(s) of experience in ICU,ER ; Joined: Jul '03; Posts: 614; Likes: 299I haven't read all the posts so sorry if I am beating a dead horse......
but I personally think it would be silly and petty to report a medic for
doing the right thing.
As far as the patient/family refusing care (the o2)..... why on EARTH did they call 911 then?? That is such a pet peeve of mine. People coming to the ER on "the brink of death" and then refuse treatments/care.
This patient could have loaded up in the car with their 2L cannula and ridden to the ER.
Jan 29, '07Joined: Apr '02; Posts: 38,771; Likes: 16,375I, for one, am learning so much from you all. Thank you for the opportunity to see varying opinions and learn.